HIV in Albania: A National Programme Report

HIV in Albania:
A National Programme Report
September 2014
HIV in Albania: A National
Programme Report
September 2014
Prepared by:
Alison Brown, Sergii Dvoriak and Valerie Delpech with
assistance from the Institute of Public Health, Albania
Keywords
ACQUIRED IMMUNODEFICIENCY SYNDROME
AIDS
ALBANIA
HIV
NATIONAL HEALTH PROGRAMMES
PUBLIC HEALTH
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List of contents:
Introduction ............................................................................................................................. 2
1.
1.1
Country epidemic: latest trends.............................................................................................. 2
1.2
National response to HIV ........................................................................................................ 2
1.3
Health Care Provision ............................................................................................................. 3
1.4
The Global Fund ..................................................................................................................... 4
2.
Aims and objectives ................................................................................................................ 4
3.
Methods ................................................................................................................................... 4
4.
Findings ................................................................................................................................... 4
4.1
Strengths ................................................................................................................................. 4
4.2
Challenges ............................................................................................................................... 5
Priority areas, recommendations and targets ......................................................................... 13
5.
5.1
Priority area 1: Develop sustainable governmental political and financial commitment...... 13
5.2
Priority area 2: Establish antenatal screening and increase access to HIV testing................ 14
5.3
Priority area 3: Develop an effective HIV treatment and care programme .......................... 15
5.4
Priority area 4: Review and improve access to, and scope of harm reduction services ........ 15
5.5
Priority area 5: Develop friendly and non-judgemental services and reduce perceived HIV
stigma and homophobia .................................................................................................................... 16
Appendix One: Terms of Reference .................................................................................................... 17
Appendix Two: Summary of meetings ................................................................................................ 21
Appendix Three: Presentation given to the country co-ordinating team on day four. .......................... 24
References ............................................................................................................................................. 26
Abbreviations:
AIDS
ART
ARV
EU
GP
GF
HR
HCV
HIV
IPH
IBBS
MSM
MMT
NGO
NNRTI
NRTI
NSP
OST
OI
PI
PLHIV
PWID
SW
STI
TB
TUH
VCT
WHO
Acquired Immunodeficiency Syndrome
Antiretroviral Therapy
Antiretroviral
European Union
General Practitioner
Global Fund
Harm Reduction
Hepatitis C Virus
Human Immunodeficiency virus
Institute of Public Health
Integrated bio-behavioural Survey
Men who have sex with men
Methadone Maintenance Treatment
Nongovernmental Organization
Non‐Nucleoside Reverse‐Transcriptase Inhibitors
Nucleoside Reverse-Transcriptase Inhibitors
Needle and Syringe Exchange Programme
Opioid Substitution Therapy
Opportunistic Infections
Protease Inhibitor
People Living with HIV
People who Inject Drugs
Sex Workers
Sexually Transmitted Infections
Tuberculosis
Tirana University Hospital
Voluntary Counselling and Testing
World Health Organization
Executive summary
The key aim of Albania’s national HIV strategy (2009-2014) was to ensure the country
continued to have a low prevalence epidemic. At the close of the strategy, this aim has been
realized with only 699 diagnoses reported by end 2013; this is equivalent to 3/100 000
population. Contributing to this success is the availability of free health care, HIV testing and
HIV treatment which have reduced barriers for those most at risk. Albania also benefits from
passionate and committed clinical and public health expertise with established HIV
surveillance systems for monitoring testing and epidemiological trends and established and
supportive NGOs.
While HIV prevalence remains low, the potentially unrecognized epidemic in men who have
sex with men (MSM), the large proportion of people unaware of their HIV infection, and the
high rates of sharing of needles and syringes among people who inject drugs indicate there is
a risk that the HIV situation within Albania will deteriorate.
This report details findings from a WHO mission to identify the strengths and challenges in
the programmatic efforts related to the Albanian HIV epidemic, and the development of
recommendations to improve the public health response in five priority areas. These five
priority areas and recommendations will form part of an application to The Global Fund in
early 2015.
1. develop governmental political and financial commitment and partnership with
NGOS to establish sustainable HIV prevention, and management and treatment
programmes;
2. establish antenatal screening and increase access to HIV testing (including access
to rapid tests), establish routine testing for patients presenting with HIV indicators
diseases and outreach to key populations (men who have sex with men (MSM), sex
workers (SW), people who inject drugs (PWID) and persons who attend methadone
maintenance programmes;
3. develop an effective HIV treatment and care programme to ensure high
enrolment and retention care and high ART coverage. Establish a board with
responsibility for the management of HIV care, including the procurement and
provision of HIV treatment and laboratory tests (CD4 counts, viral loads and drug
resistance tests);
4. review and improve access to, and scope of harm reduction services for key
populations. This should include optimal dosing, ongoing psychological support, and
provision of methadone in prison settings and for opioid users;
5. develop friendly and non-judging services and reduce stigma and discrimination
for people living with HIV (PLHIV), sex workers, PWID and towards Roma people
and lesbian, gay, bisexual and transgender (LGBT) communities.
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1. Introduction
1.1
Country epidemic: latest trends
Albania has a low-level HIV epidemic with 699 cumulative cases diagnosed by the end of
2013 (1). The first case was diagnosed in 1993 with very low number of cases reported
annually in the first decade (1993-2002). Between 2008 and 2013, the number of HIV
diagnoses more than doubled from 48 in 2010 to 124 in 2013. The ratio of male to female
cases has been consistently around 2:1 with the majority of cases diagnosed between the ages
of 25-44 years (60%) followed by 45-54 years olds (17%). This indicates that Albania is
likely to have an underreported and unrecognized HIV epidemic in men who have sex with
men (MSM) and possibly among people who inject drugs (PWID).
To date, 122 deaths have been reported among people living with HIV, corresponding to a
crude death rate of 17% among the HIV diagnosed population. About half of diagnoses were
reported in the capital, Tirana (52%) followed by the cities of Durres, Elbasan and Vlora. All
but three of the 36 districts in the country have reported a least one case.
People are tested for HIV infection in a variety of settings including voluntary counselling
and testing (VCT, available in 12 cities), inpatient hospital, Public Health Institute, general
practitioners and specialist physicians. Over three quarters of patients are diagnosed with a
CD4 count under 350 cells with 52% presenting with a CD4 count under 200 cells. This
indicates that a relatively high proportion of people living with HIV infection in Albania are
likely to be unaware of their HIV infection. All HIV positive tests are sent to the Institute of
Public Health (IPH) reference laboratory for confirmation on western blot based in Tirana.
Following an HIV positive diagnosis, patients are referred to Tirana University Hospital
(TUH) which cares for all patients living with diagnosed HIV infection across Albania. As of
March 2014, the total number of patients enrolled on anti-retroviral therapy (ART) was 335
(first and second line).
A full analysis of the Albanian epidemic and the national surveillance systems is included in
a separate report.
1.2
National response to HIV
Albania’s national response to HIV is guided by the National Strategy of Prevention and
Control of HIV/AIDS in Albania 2009-2014 (2). Its overall goal was to ensure that Albania
remains a low HIV prevalence country, delivered through three strategic priorities:
prevention of new HIV/STI infections in key groups and the general population; improved
treatment, care and support for people living with HIV; and further system infrastructure and
health provider capacity development to ensure high quality and timely service to all people
affected by HIV/AIDS.
A new HIV strategy is currently under development and scheduled for publication at the end
of 2014. The working group comprises the Ministry of Health, the IPH, the Hospital of
Infectious Diseases, the Institute of Health Insurance and representation from the people
living with HIV (PLWHA) association. The development process has been collaborative, and
the work builds upon the previous strategy, but incorporates a number of new and/or reenforced elements. These include:
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•
•
•
•
•
•
•
emphasizing the need for timely and accurate epidemiological data through case
reporting and regular integrated bio-behavioural surveys (IBBS);
prioritizing the need for antenatal screening for HIV;
re-emphasizing the importance of targeted prevention activities among key populations
(particularly men who have sex with men (MSM) and people who inject drugs (PWID);
improving the provision of care and treatment for people living with HIV (revising the
CD4 threshold for ART in line with the consolidated World Health Organization (WHO)
guidelines) (3);
early diagnosis of HIV, and diagnosis and treatment of co-infections;
updating ART provision); and
promoting provider initiated HIV testing in routine health settings.
Albania has a number of other strategies relevant to HIV that relate to health more broadly.
Firstly, the Health System Strategy (2007-2013) (4) aimed at:
1.
2.
3.
4.
increasing the capacity and efficiency of current health services;
increasing access to health services;
improving health system financing; and
improving health system governance.
In addition, Albania had a Public Health and Health Promotion Strategy entitled “Towards a
Healthy Country with Healthy People” (5). This identifies key public health issues; sexual
and reproductive health is included with prominence particularly given to HIV prevention
among school-aged populations. Finally, the national strategy on tuberculosis (TB) for
2013-2019 (6) makes explicit the need to undertake HIV testing among all people with TB,
but recognises the capacity and referral challenges in this area.
1.3
Health Care Provision
Throughout Albania, access to health care is free through a health insurance scheme.
Children, people past the age of retirement, and people who are unable to work receive free
health care. People who are eligible for work but who are not employed receive health care
dependent upon registration of intention to find paid employment. Whilst contact with health
services is free, patients are asked to pay a contribution (usually <$40) towards interventions
and prescriptions. The exception is HIV, where first line anti-retroviral therapy (ART) is paid
for by the government, with second line therapy is paid for by the Global Fund.
The Ministry of Health is working towards a redesign of the health care structure. This
involves creating a system of health care funded through taxation. It is hoped that this
change, planned for 2017, will reduce bureaucracy and simplify health care access at the
point of care. Further changes include the introduction of electronic patient records. It is
anticipated that these developments will facilitate tracking of patients across different health
care services. Discussions are planned as to how the sensitivities of certain medical
information (including HIV), included in patient records, will be protected.
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1.4
The Global Fund
Albania’s response to the HIV epidemic has been supported by a Round 5 grant from The
Global Fund to fight AIDS Tuberculosis and Malaria (GFATM). This funding expired in
2012, and Albania is currently in the process of preparing an application for Round 10 with
deadline for submission in October 2014.
The Round Ten application is focused on seven key areas. These have been selected as they
are vital to ensuring that Albania remains a low prevalence country, and because they are
areas in which funding gaps have been identified. They comprise: prevention programmes for
MSM and transgender people; prevention programmes for PWID and their partners;
prevention of mother to child transmission; treatment, care and support; TB/HIV; health
information systems, monitoring and evaluation; and programme management.
2. Aims and objectives
The aim of this mission was to evaluate the strengths and challenges of the HIV epidemic in
Albania and to generate recommendations for improving outcomes and impact of the national
response. These recommendations will be considered for the concept note for The Global
Fund application in early 2015. Appendix One outlines the Terms of Reference for this
mission.
3. Methods
The evaluation builds on a desk review and a country mission which took place from
8 to 11 September 2014 to Tirana, Albania. Information and data were collated from
secondary sources including national publications, epidemiological reports, WHO and Global
Fund reports. The WHO experts also met with the Ministry for Health, epidemiologists from
the Institute of Public Health, clinicians and procurement professionals at TUH, VCT
workers and Nongovernmental Organization (NGO) representatives (Aksion plus, Stop
AIDS, and People living with HIV and AIDS (PLWHA), Albanian Lesbian and Gay
Association (ALGA). A full list with names and organizations is provided in Appendix Two.
Preliminary feedback on the priority areas was presented on day four to the country
coordinating group (Appendix Three).
4. Findings
4.1
Strengths
Albania remains a country with low HIV prevalence by the close of its national strategy.
There are several key strengths both in the provision for HIV care and in response to the HIV
epidemic. Firstly, the availability of free health care, HIV testing and HIV treatment is not
only beneficial for the individual patients living with HIV but reduces barriers for testing
among those populations most at risks.
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Secondly, Albania benefits from a central public health laboratory with public health
infrastructure, a dedicated AIDS coordinator and well established HIV prevention activities
as well as a small number of harm reduction activities. The IPH has passionate and
committed epidemiological expertise with established HIV surveillance systems for
monitoring, testing and epidemiological trends. Thirdly, Albania has highly skilled HIV
clinicians and a dedicated HIV clinic with free and accessible antiretrovirals (ART).
Fourthly, the country has committed and active NGOs that provide a critical role in delivery
of prevention activities and services. Finally, there is strong legal framework protecting those
living with HIV (2008) and other key groups such as LGBT against discrimination (2010).
4.2
Challenges
While Albania remains a low HIV prevalence country, the rise of new HIV diagnoses in
Albania is concerning. The large majority of people present at a late stage of infection and the
crude death among the diagnosed population is 17%. These data underscore a large
undiagnosed HIV population and an urgent need for expanded testing. Current surveillance
show a 2:1 male to female ratio which implies that MSM and PWID activities are underreported among newly diagnosed cases.
Whilst those diagnosed and in care benefit from free treatment, stock outs are frequent and
drug regimens restricted to available generics through a cumbersome and bureaucratic
process. Whilst there are some dedicated NGOs, the country would benefit from a stronger
network of NGOs with improved coordination and programmes better targeted to key
populations.
4.2.1 Governmental political and financial commitment
In order to ensure that the response to the HIV epidemic is proportionate and sustainable, it is
important to obtain governmental commitment. Albania provides free health care through its
public system and also has a few private providers. During the Global Fund Round 5, NGOs
developed a number of prevention and harm reduction initiatives with government support,
but since funding ended in 2012, these activities have not been sustained. The programmes
have been evaluated by the National Commitments and Policies Instruments as inadequate
and under-funded, particularly among key populations (7). The commitment required is
therefore not only financial but also political to demonstrate the commitment to the success of
sustainable programmes.
In the context of HIV, NGOs focus on harm reduction for PWID and lobby for rights for
people living with HIV. There are three NGOs focusing on LGBT issues; however the focus
of these organizations is LGBT equality and rights. NGOs feel in competition for the limited
funding and the degree of coordination is currently limited. While NGOs are able to reach
most at risk populations more effectively than public health authorities, their impact is limited
due to lack of funds and required skill set. Greater partnerships between government/public
health and NGOs are therefore required.
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The Albanian response to HIV/AIDS had been focused on prevention and includes measures
of primary, secondary and tertiary prevention. A large proportion of measures for HIV/AIDS
prevention is based on health education more generally. Due to the low level of HIV/AIDS
risk in Albania these measures are predominantly focused on promotion of protective
behaviour in the general and adolescent populations and on prevention of determined risk
behaviour within certain most–at–risk groups. Current HIV testing services and public health
messages are not targeted at MSM and PWIDs.
4.2.2 HIV testing and screening
Albania needs to scale up its provision of HIV testing facilities with urgency. Investment in
HIV testing will prevent mortality, reduce morbidity and lengthy hospital stays.
Furthermore, a reduction in the size of the undiagnosed HIV population will reduce onward
transmission through ensuring PLHW are aware of their infection and have access to ARV to
decrease the risk of onward transmission. However, the uptake of HIV testing remains too
low as indicated by the high proportion of patients diagnosed with a late stage of HIV
infection.
Antenatal screening and testing
There is currently no antenatal screening for HIV, hepatitis or syphilis in Albania. In 2013,
there were six cases of mother-to-child transmission of HIV with some cases of congenital
syphilis also reported. Assuming an HIV transmission rate of 25% among untreated HIV
positive women (8); this means at least 24 HIV positive women were pregnant in Albania in
2013. This is likely to be a conservative estimate most people are diagnosed late and other
infants who acquired their infection vertically may not yet be symptomatic and presenting for
HIV testing.
The establishment of an antenatal screening programme is feasible since most women attend
at least one gynaecological/obstetrician appointment during the course of their pregnancy.
The benefits of an antenatal screening programme are clear. The absence of antenatal
screening is not only putting infants at risk of transmission, but also deprives women living
with HIV opportunities for prompt diagnosis and treatment. The higher median CD4 counts
among women compared to men internationally demonstrates that antenatal screening also
works to reduce undiagnosed HIV infection in the general population, particularly women
combined with partner notification. From surveillance perspective, data from an antenatal
screening programme would also provide robust estimates of national prevalence, since
pregnant women are broadly representative of the general population.
Voluntary Confidential Testing
Centres for VCT have been established since 2005 and are available in 12 prefectures Tirana, Durres, Vlora, Lezha, Shkodra, Korca, Gjirokastra, Berat, Fier, Elbasa, Kukes and
Peshkopi. 1 The number people tested in VCT settings increased from 250 tests in 2005 to
3,063 in 2013.
1
According to the information obtained during the mission in August 2014, voluntary
testing is defined as testing which is done upon request of a person, without prior
consultation with a healthcare professional. Recommended testing is the one done upon
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During testing, clients are interviewed in relation to their demographic details, sexual history
and reason for test. Rapid testing is undertaken using venous samples. Clients found to be
HIV positive receive post counselling care from a psychologist, who also refers them to the
HIV clinic in TUH. Few new diagnoses are reported through VCTs (exact number not
reported) indicating that these are largely attended by low risk individuals. Staff at the Tirana
clinic report around 50 patients self-refer themselves for testing each year. Interviews with
VCT staff indicate that the majority of tests are conducted among persons as part of a visa
requirement for work or study abroad. There is little outreach activities in relation to HIV
testing.
VCT clinics are therefore currently underutilised. The location of the Tirana VCT clinic (the
only clinic visited during the mission) within a government building is likely to deters those
most in need of testing from attending. Partnerships with NGOs are essential to reach key
populations at risk of HIV with specific focus on MSM, PWID and sex workers. Capacity
building for outreach is important to reach key populations at risk of HIV, with specific focus
on MSM, PWID and sex workers.
A redesign of VCT services is needed to better target and outreach to key populations and
link them to friendly and integrated services is required. In addition to HIV testing, services
should consider the provision of STI screening and sexual health, contraception services,
social and legal advice and general medical care as well as outreach activities.
The location (and therefore accessibility) of the service as well as appropriate training of staff
to ensure a non-judging and welcoming attitude is critical to its success. Integration of
services would greatly benefit vulnerable persons with high health needs in addition to their
risk of HIV infection. Increase partnership between public health and NGO services may be
a suitable model for delivering integrated services. Provision of comprehensive sexual health
care by trained and dedicated staff in a gay friendly environment is also recommended. HIV
testing need not include lengthy pre-test counselling, nor use venous samples, both of which
may be barriers for testing. Instead, a finger prick test can be under taken rapidly with
limited training, and is much more accessible to key populations.
Use of media campaigns and promotions could increase awareness of HIV and promote the
benefits of HIV testing. The European HIV testing week provides an excellent opportunity to
offer HIV testing to key groups in partnership with NGOs. It is also vital to that patients
found to be positive are actively followed up to ensure they reach treatment and care services
and are provided with ongoing support.
Provider led testing in clinical settings
The current extent of provider-led testing in clinical services is unknown. Such an
intervention is likely to be important given the high proportion of patients diagnosed at a late
stage of HIV infection. While the TB strategy emphasises the importance of provider led
screening among TB patients, no data are available on the uptake of testing in outpatient
settings, including TB clinics.
recommendation from healthcare providers who have established risk factors while
interviewing a client/patient.
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Adequate training as well as a cultural shift is needed to increase routine HIV testing among
patients with HIV indicator diseases. Universal offer of a HIV by clinic staff could be piloted
within respiratory, TB, and dermatological outpatients given that the most common AIDS
defining illnesses are PCP, TB or Kaposi’s sarcoma (informed by surveillance data). Patients
diagnosed with viral hepatitis B and C should also be offered an HIV test as part of routine
care. Training of health professionals is critical to the success of testing programmes in these
setting. A sexual or drug history is not required during pre-test counselling. Increase provider
led, routine offering of HIV test to in hospital setting
NGOs in contact with key populations including PWID and sex workers currently do not
incorporate point of care testing as part of their services. Patients attending methadone
maintenance treatment programmes (MMT) and needle and syringe exchange programmes
(NSP) should routinely be offered an HIV test at least annually.
4.2.3 HIV care and treatment
Link to, and retention in HIV care
HIV treatment and care have been available since mid-2004 through the inpatient and
outpatient (established through global funds in 2007) units based at the TUH based in Tirana.
Following a positive HIV diagnosis, patients are referred to a psychologist and referred to
TUH for their HIV treatment and care. There is no active follow up of patients newly
diagnosed who do not attend care – otherwise known as those who are lost to follow up
(LTFU).
Since the epidemic began, 699 patients have been diagnosed with HIV in Albania. Of these,
it is known that fewer than half (335 (48%)) are currently receiving treatment and 122 (17%)
have died. While a number may be receiving HIV care but not treatment, there is no preART register to monitor this. Therefore, 242 (35%) patients ever diagnosed with HIV remain
unaccounted for in current monitoring systems. Once established in care and receiving
treatment, clinic records are used to monitor retention in care. However, these data are not
routinely reported. A representative from the PLWHIV association noted that co-ordination
between paediatric and adult care for HIV was not optimal, with particular difficulties for
adolescents transitioning to adult HIV care.
The relatively small size of the diagnosed population and the presence of only one treatment
setting mean it should be feasible to follow up patients who are LTFU. This exercise is
important to reduce mortality and morbidity. Factors that may be associated with LTFU in
Albania may include financial and practical difficulties attending care (TUH is the only
setting in Albania providing care) and consequences due to ART stock out. Strategies to
address delays in enrolment and retention in HIV care should be developed. This could
include developing systems of SMS reminders for appointments and active follow-up through
involved peer support through NGOs.
Once in care, it is recommended that IPH and TUH work together monitor annual retention in
care by patient residence and other important factors. It is recommended that the time
between HIV diagnosis to the first CD4 count taken following diagnosis is routinely
monitored for each HIV positive report. This will enable measurement of the extent of loss
to follow up after diagnosis and will also inform whether an ambulatory HIV service for
those residents outside of Tirana is required. Infrastructure to establish a clinical database for
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patient care and transfer of data (e.g. CD4 and viral load information) to the national IPH is
required to produce and monitor continuum of care indicators.
HIV treatment
HIV treatment and care have been available since mid-2004 through the inpatient and
outpatient units based at the TUH. The number of people receiving ART has doubled in two
years (from 161 in 2011 to 335 in 2014).
The Albanian national guidelines on ART are based on WHO 2004 guidelines 1 and
recommendations of 2010 2; national guidelines have not been updated since 2007. These
guidelines indicate ART initiation based on CD4 counts (<350 cells/mm3) and other clinical
criteria. Second line drugs are funded through The Global Fund continuation of services
agreement. Of those receiving treatment in 2013 (316 adults and 19 children), 88 were
receiving second line therapy. Table 1 outlines the number of patients receiving each ART
regimen.
Table 1: Number of patients receiving ART by drug class and regimen, March 2014
Drug class
NRTI
NNRTI
PI
Drug regimen
ZDR/3TC
FTC/TDF
TDF
3TC
ABC
ddl
ZDV
EFV
LPV/r
ATZ
Number receiving
191
99
18
17
6
11
1
233
80
3
It is important for Albania to review the current national ART guidelines to consider their
continued relevance in light of the current WHO guidelines (3). This includes a review of the
specific recommendations from WHO guidelines with regard to populations who should start
ART regardless of CD4 count and those who should start ART with a CD4 count <500
cells/mm3.
Procurement and supply management
The current contractual process for pharmaceutical drugs is cumbersome, bureaucratic and
time consuming for clinicians and hospital administrators. Patented pharmaceuticals for HIV
treatment are deemed too expensive by the Ministry of Health. Generic drugs are available
through a governmental contract with UNICEF. This is a cheaper solution and there are
currently 10 ART regimens available at TUH which is in line with WHO consolidated
guidelines on use of ARTs (3).
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Stock-outs of ART are frequent particularly over the summer resulting in patients not
receiving any treatment or switching of drugs regimens depending on drug availability. It is
estimated that ART is not available for approximately three months of every year. An almost
doubling in the numbers of persons requiring ARVs is expected in the next three years to
>600 and with increased testing uptake, this is likely to be substantially higher. The new
procurement system should have the ability for forecasting of drugs and diagnostic required.
ART stock outs and inflexibility of procurement specific regimens is likely to have
contributed to patient deaths, particularly among those presenting late. ART stock outs also
contribute to the relatively high proportion of patients currently on second line regimens
which means prescribing decisions are based upon clinical indications only.
Finally, the lack the limited availability of ART means patients are prescribed with
sometimes only one month drug supply. This means frequent attendance to TUH which will
negatively impact on patients having to take time from work or those travelling from outside
of the capital.
It is recommended that an advisory group is set up to improve the ART procurement and
provision process. This group should be comprised of HIV clinicians, procurement
personnel, ministry of health officials, Institute of Public health as well as representation
from people living with HIV and AIDS. In addition to the review of current national ART
guidelines against WHO guidelines (3), this group could also put forward international
pressure for wider availability of generic drugs. The availability of CD4, viral load and drug
resistance testing also seem to be associated with budgeting issues and would fit under the
agenda of this group.
Clinical monitoring
Viral load and CD4 monitoring is not performed routinely due to shortages of kits, although
according to interviews with staff, the situation is improving. This means that the proportion
of patients adherent to ART and treated successfully cannot be measured. This is an
important public health measure since such individuals have negligible risk of passing on
their infection though sex. WHO guidelines indicate that patients should have viral loads and
CD4 counts measured twice a year (3).
Drug resistance monitoring is not available. While WHO does not recommend drug
resistance monitoring for countries with limited resources, guidelines indicate that virological
failure should be used to inform decisions to switch to second line regimens (3). The absence
of viral load information therefore has clinical consequences with ART regimen changes
instead based upon clinical indications and drug availability.
HIV positive cases are not screened for TB because there is no PPD skin test available. TB is
currently diagnosed through x-ray and other clinical indications.
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4.2.4 Harm reduction among PWID and prisoners
Harm reduction (HR) is an important drug policy approach focusing not only on individuals
but also on community health. It refers to policies and programmes aimed at reducing the
harms associated by drug use, but not drug use per se (11). Key features of HR include:
reducing the harm caused by drugs, rather than drug use; acceptance that drug consumption is
an inevitable component of modern society and will never eliminated; the priority is
immediate realistic goals; harm reduction corresponds to basic values such as pragmatism
and human rights concepts.
PWID
Survey data indicate that 1% of PWID in Albania are living with HIV infection. Frequent
injection is common with 44% reporting multiple injections daily. The levels of needle
sharing and condomless sex are high, and could result in a major outbreak if HIV was
introduced among this population.
HR programmes for PWIDs began in Albania in 1995. They are currently offered by four
NGOs (Aksion Plus, APRAD, Stop AIDS and UKPR) operating in the field of drug demand
and HIV/AIDS reduction with a clear focus on harm reduction activities, as well as by the
public VCT Centres. Harm reduction responses are focused on NSP, MMT, peer education,
information and counselling, basic medical support and psychosocial support.
NSP services are offered only in the capital Tirana through NGO facilities. Through such
programmes, PWIDs are not only exchanging needles and syringes but also obtaining
condoms, disinfectants, information and education materials, as well as social and
psychological assistance. By the end of 2010, a total of 4050 IDUs had benefited from needle
exchange programmes. The number of distributed syringes is about 175 per year, however
these data only relate to attendees of NSPs and there is likely to be sufficient distribution
across the country as a whole.
In 2011, survey data indicated that 62% of PWID had received treatment for their drug
addiction. Of those receiving treatment, 86% were receiving MMT and 14% were under
detoxification with other drugs. However, it is likely that the estimated proportion of PWID
who had received treatment is biased towards people who had attended drug services.
The current average dose of methadone of 51mg/day is well below the recommended dose of
80-120 mg. There is a risk that clients may continue to inject drugs because of the low doses.
NSP staff have anecdotally reported that clients who attend MMT in the morning return in
the afternoon to use the syringe exchange facilities. It is recommended to undertake a study to
measure retention and success in MMT.
There is a lack of recognition among medical professionals that opioid dependence is a
chronic disease, and methadone is currently only prescribed by psychiatrists. Consideration
should be given to training general practitioners and family doctors in this field. This will
provide a more holistic approach to the medical care provided to clients. While psychological
support is provided, medical help is limited and needs to be incorporated as part of the
service.
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Currently services are also missing opportunities for diagnoses of HIV and other blood borne
viruses. Most MMT clients have not been tested for HIV and HCV, one of the reasons being
that the misconception that available rapid tests require venipuncture which can be difficult
for PWID. It is recommended that, as part of MMT services, clients are offered rapid finger
prick tests for HIV and other BBV and are screened annually. Vaccination against hepatitis
B for newborns has been available since 1994 and the IPH has offered vaccinations against
hepatitis B to PWIDs free of charge since 2001, but the uptake is not known 2.
Given ongoing police interference in drug treatment and prevention programmes, education
and training for police officers to explain the importance of the HR approach.
Prisoners
Stop AIDS also offers harm reduction activities to prisoners in six prisons, focusing on
information, counselling, peer education, HIV, syphilis, hepatitis B and C testing, training of
medical and psycho-social personnel and provision of condoms.
There is limited prevention initiatives in Albanian prisons with fewer than 20 prisoners
currently enrolled in MMT programmes. Since prisons have a zero tolerance drug policy,
NSP are banned in prison settings.
However, the literature indicates that despite such policies, injecting drug use in prison
setting is prevalent, with an estimate of between 3 and 53% of all inmates injecting at some
point while incarcerated (12,13,14). While PWID do so less frequently in prison settings
compared to community settings, HIV transmission risks are markedly elevated within
prisons because a scarcity of injection equipment leads to increased high-risk sharing (15).
This may in part contribute to findings that prior incarceration is independently associated
with HIV infection (16).
The high documented rates of sharing of injecting equipment within prisons indicate the need
for prison staff to be trained in harm reduction concepts and interventions. There is
convincing evidence that NSP should be provided in prisons. It is also recommended to
conduct a special study of prison population because without this a majority of public health
issues remain unrecognized or underestimated (12).
4.2.5 Social determinants and legislation
The HIV and AIDS Act (2008) and the anti-discrimination act (2011) stipulate that PLWH
have a right to privacy, normal education, health care, housing, and non-discriminatory
relations in all aspects of their lives. While there is a strong legal protection for those living
with HIV, the society for people living with HIV report high levels of HIV stigma with
anecdotal evidence of challenges, and education and employment discrimination.
While Albania has anti-discrimination laws that relate to the LGBT society, it remains a
hetero-normative society. LGBT are not visible in the media, and LGBT NGOs report high
levels of stigma including verbal and physical abuse. It is likely that the high proportion of
gay men reporting also being in sexual relationships with women, and the few reports of
2
http://www.emcdda.europa.eu/publications/country-overviews/al#harm
12 | P a g e
same sex contact at HIV diagnosis is in part due to actual and/or perceived homophobia in
society.
Gay, bisexual and other MSM remain a hidden and stigmatized population in Albania.
Despite strong anti-discrimination laws, anecdotal evidence suggests that MSM are likely to
be victims of verbal or physical abuse. Consequently most MSM are not open about their
sexual identity.
Despite a positive legal framework, stigma and discrimination of PLHIV and LGBT persons
remains a major challenge in Albania. It is recommended to organize workshops and training
of key staff and in particular those from the health care, police force and education sectors.
Unless attitudes are challenged and changed, PLHIV and MSM will remain marginalized and
isolated and at risk of ill-health.
Evidence suggests police interfere in treatment and prevention programmes. There is a new
legislation about drug turnover and prevention activities, but still in action the Criminal Code,
which allows police to harass PWID without reasonable cause.
There are very limited data relating to sex workers and sex work in Albania. Sex work is
illegal and carries the risk of prosecution and custodial sentences for both sex workers and
their clients. There are anecdotal reports of sex workers being imprisoned and beaten by
police. It is thought that a disproportionate number of sex workers belong to Roma
communities. No prevalence survey or outreach testing has been conducted in this group.
There is a large body of evidence showing the benefits of education on behaviour and
improvement of health. Greater general awareness of HIV through education campaigns as
well as comprehensive sex education programmes in schools is recommended. In line with
WHO recommendations (3), Albania should focus efforts and resources to key populations.
5. Priority areas, recommendations and targets
We have set out five priority areas below, each with key recommendations and targets. The
priority areas and recommendations were discussed at the AIDS coordination group meeting
on the final day of the mission (see Appendix Two).
5.1
Priority area 1: Develop sustainable governmental political and
financial commitment
5.1.1
Recommendations
•
•
•
•
Produce a national HIV strategy with full commitment from all parts of government,
NGOs and PLHIV.
This strategy should emphasize all aspects of HIV prevention, treatment and care and
key populations most at risk of HIV and other STIs.
The Global Fund application contains explicit reference to sustainability of
programmes, both financially and politically.
Contracts to be developed between government and Nongovernmental Organizations
to improve access to, and content of, prevention services aimed at key populations.
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5.1.2
•
•
Targets
National HIV strategy published by end 2014.
Contracts established for targeted HIV prevention between government and NGOs by
2015.
5.2 Priority area 2: Establish antenatal screening and increase access to
HIV testing
5.2.1
•
•
•
•
•
5.2.2
•
•
•
•
•
•
•
Recommendations
A universal antenatal screening programme should be implemented with urgency,
including testing for HIV, hepatitis B/C and syphilis.
HIV testing among most-at-risk populations should be scaled up.
VCT services should be redesigned to:
o target and outreach into key populations
o provide gay-friendly services
o use non-medical staff to offer tests
o use rapid HIV testing using finger prick samples
o and omit detailed pre-test counselling process
o ensure people tested positive are actively followed up to HIV treatment and
care services, ensuring support where needed
Provider led, routine HIV testing among patients with HIV indicator diseases should
be increased, with HIV tests offered for patients presenting with AIDS defining
illnesses.
Provide integrated STI screening and other sexual health services within HIV-related
services (e.g. VCT clinics, methadone and needle exchange programmes).
Targets
90% of pregnant women to be offered and tested for HIV by end 2016.
50% of VCT clinics to contain an outreach component of their programme by end
2016.
100% of VCT clinics to use finger prick rapid HIV testing by end 2015.
90% of PWID and SW clients to be offered and have an HIV test annually by end
2016.
90% of patients with clinical symptoms of AIDS defining illness (e.g. TB,
Pneumocystis pneumonia, etc.) to be offered and tested for HIV by end of 2016.
90% of patients with viral hepatitis B and C to be offered and tested for HIV by end
2016.
Reduce late diagnoses rates by 50% by 2016.
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5.3 Priority area 3: Develop an effective HIV treatment and care
programme
5.3.1
•
•
•
•
•
•
•
•
5.3.2
•
•
•
•
•
•
•
Recommendations
Introduce strategies to address delays in enrolment and retention in HIV care and
ART.
Provide IT infrastructure and establish a clinical database which also allows or
transfer of epidemiological and quality of care indicators (e.g. CD4 and viral load
information) to the national Institute of Public Health.
Ensure monitoring of patient CD4, and viral load testing is available for each patient
twice a year.
Introduce screening for TB for patients diagnosed with HIV.
Provide better integrated care for children and adolescents living with HIV and their
transition into adult care.
Establish an advisory group to oversee procurement and provision of ART and
laboratory tests (CD4 and viral load).
Review the current ART treatment guidelines to ensure they are consistent with WHO
guidelines. This includes specific recommendations for those who should start ART
<500 cells and those who should commence treatment regardless of ART.
Introduce a procurement system with a formalized methodology for forecasting.
Targets
90% of patients diagnosed with HIV to be established in HIV care within three
months of diagnosis by 2016.
90% of diagnosed and eligible for ART patients provide ART.
90% of persons with opportunistic infections to receive free and prompt treatment.
For national ART guidelines to be reviewed against WHO treatment guidelines by
end 2015.
0% stock outs by 2016.
All patients to have CD4 test at time of HIV diagnosis and two CD4 and viral load
counts each year.
80% of patients receiving ART for at least 12 months to be virally suppressed.
5.4 Priority area 4: Review and improve access to and scope of harm
reduction services
Recommendations
•
•
•
•
Offer and recommend a test for HIV and hepatitis B and C on entry and every year.
Review and consider raising the methadone dose from an average of 51 mg/day to 80120 mg/day.
Implement routine monitoring of retention and outcomes for MMT. Provide training
of methadone management to a wider range of health professionals.
Provide training to prison staff on harm reduction interventions.
15 | P a g e
•
Provide access to basic medical care and psychological support at MMT and needle
exchange clinics.
•
Targets
•
•
90% of MMT clients to be tested for HIV and hepatitis on entry to services.
Conduct review of methadone prescribing to ensure clients are on optimal dosing by
end 2015.
5.5 Priority area 5: Develop friendly and non-judgemental services and
reduce perceived HIV stigma and homophobia
Recommendations
•
•
•
•
Seek technical support in order to develop supportive and non-judging services for
key populations.
Design and deliver workshops and training of key staff (health care, police and
education) on HIV and LGBT awareness.
Design and hold workshops to help create enabling environments and increase
capacity to deliver HIV prevention programmes and services to key populations (SW,
PWID, MSM).
Generate greater awareness of HIV through education campaigns in addition to
comprehensive sex education programmes in schools.
Suggested targets
•
•
Run series of workshops with key staff by end 2015;
Plan and redesign of HIV services (VCT, MMT etc.) to ensure they are friendly and
non-judgemental by 2016.
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Appendix One:
Terms of Reference
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTÉ
REGIONAL OFFICE FOR EUROPE
BUREAU RÉGIONAL DE L'EUROPE
ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ
WELTGESUNDHEITSORGANISATION
ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО
REGIONALBÜRO FÜR EUROPA
Evaluation of the HIV programmes in Albania
7-11 September 2014
1.
Background
Albania has a growing HIV epidemic. By the end of 2012, Albania reported a cumulative total
of 577 HIV cases to the joint database of the WHO Regional Office for Europe and the
European Centre for Disease Prevention and Control (ECDC). The rate of newly diagnosed
HIV infections in 2012 was 2.9 per 100 000 population; the rate has steadily increased since
2006 when it was 1.0 per 100 000 population. The majority of new HIV cases in 2012 were
male (70%). Among the newly diagnosed HIV cases there are only 25,6% with information
about transmission mode which implies a possible gap in surveillance. Among the general
population, HIV testing coverage is low; in 2011 only 2 590 people were tested. Only 2% of
Albanian health facilities offered HIV testing services. Undiagnosed HIV is a major issue to
achieving the individual and public health benefits of ART. Some 335 people were receiving
ART in 2013. Concerns may exist regarding different treatment regimens, national ARV
supplies and a range of antiretrovirals used in Albania. Despite its currently low HIV
prevalence, considering existing gaps and challenges in the healthcare system, Albania is at
a high risk for an expanding epidemic in the region.
Country’s response to the HIV epidemic is supported by the Global Fund (TGF) grant and the
country is reliant on TGF in covering cost of HIV treatment. The country is in the process of
preparing an application for an HIV grant which requires external technical support in terms
of reviewing the current situation and aligning with the WHO guidelines and
recommendations.
WHO and the Global Fund have Cooperative Agreement regarding the provision of WHO
technical assistance to applicants to the Global Fund prior to submission of their concept
notes. The contract is effective during period from 1 January 2014 until 31 December 2015.
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Technical assistance is organized through external consultants and based on discussions
with the countries and the Global Fund Portfolio Managers and formal Country Requests.
Albania is eligible for the Global Fund grant county to support both national programmes on
Tuberculosis and on HIV/AIDS. The country requested the WHO Regional Office to provide
technical assistance on in both HIV/AIDS programme.
2.
Objectives of the mission
The WHO country mission will evaluate the HIV treatment and care program in Albania
along the cascade of care and services and will provide recommendations on:
standardisation of treatment regimens (including use of fixed dose combinations); reducing
the number of different regimens/ARVs; standardising diagnostic and treatment monitoring
algorithms; optimization of the HIV grant from the public health perspective so to ensure
alignment of the proposal with the WHO recommendations and high coverage with services
for those who need them.
The following key technical areas will be evaluated:
•
•
•
•
•
•
•
•
•
•
•
•
•
Population groups that are at an increased risk to acquire HIV and needs of these
key population groups
HIV services for key populations (PWID, MSM, CSW, other): special focus on HIV
prevention and diagnosis among MSM and their partners; needle and syringe
program, drug dependency treatment, ART access, penitentiaries, community
outreach including HIV testing, ARV dispense, case management/social support
HIV testing and counselling, including community-based testing for key
populations and linkage to HIV treatment and care services, routine providerinitiated counselling and testing (PICT), informed consent, CD4 count at time of
diagnosis
Early HIV diagnosis, MTCT and paediatric ART
Enrolment and retention in HIV care, including general HIV care, management of
co-infections and co-morbidities, integration of HIV/Viral hepatitis, HIV/TB,
HIV/OST services
Access to and coverage with HIV treatment and care services for key populations:
IDUs, MSM, CSW
ART: estimated need and coverage, criteria for ART initiation, retention and
adherence
ART regimens – ways to optimize and minimize number of regimens for TGF
application
ARV prices, procurements and supply chain
Monitoring of ART response: Viral load, ARV toxicity, HIVDR – ways to optimize
clinical/laboratory management and cost for TGF application
HIV/TB collaborative activities and services integration in the overall healthcare
system
National HIV strategy
National HIV treatment and care guidelines
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•
•
National VCT policies
Compliance of approaches and recommendations with the main WHO
recommendations, i.e. ‘Consolidated guidelines on the use of antiretroviral drugs
for treating and preventing HIV infection’ 2013 3 and ‘Consolidated guidelines on
HIV prevention, diagnosis, treatment and care for key populations’ 2014 4 will be
ensured.
The programme evaluation mission is expected to:
•
•
•
3.
Participants
•
•
•
4.
Review and suggest recommendations for updating the current national HIV
treatment guidelines, including possibility to rationalize existing patient regimens
and support improved drug forecasting and supply chain management;
Conduct an overall analysis of the current HIV situation in Albania and
subsequently conduct a program review;
Provide feedback and comments on the national counterparts on primary findings
during the mission and assure comments and suggestions on the national strategy
Valerie Delpech, Public Health England (lead consultant on mission)
Alison Brown, Public Health England (consultant on mission)
Sergey Dvoryak, Harm Reduction expert, Head of the Board, Ukrainian Institute on
Public Health Policy, IAS Governing Council Member, European region (consultant
on mission)
Methodology
Readily available information will be withdrawn from the secondary sources (publications,
reports, etc.) during preparation stage, the mission and after the mission for desk review
and analysis.
During the country mission WHO expert will visit relevant institutions and facilities and
discuss with key informants: policy makers, health care providers and beneficiaries, NGOs,
other national partners where appropriate. Together with local clinical experts they will also
have access to medical records of PLHIV for a review of clinical management of PLHIV.
Logistic support will be provided by the WHO and national health authorities.
3
http://www.who.int/hiv/pub/guidelines/arv2013/download/en/
4
http://www.who.int/hiv/pub/guidelines/keypopulations/en/
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5.
Time, duration and geographical sites of the mission
Mission is planned for 7-11 September 2014. Additional days are added for consultancy
assignment for national and background documents desk review (2 days), analysis and
report writing (5 days).
6.
Deliverables
Major findings and recommendations will be shared with the national counterparts and TGF
principal recipient by the end of the mission. During the mission a specific concluding
meeting will be organized and focused on presenting and discussing with the local
counterparts the immediate feedback and recommendations as a result of initial evaluation.
As a result of the mission a report with findings and recommendations on improving the
national treatment and care programme and optimization of HIV grant application will be
prepared and submitted in September 2014.
Subsequent to the mission and first submission, on request, the report has been split into
two separate reports; one outlining the HIV epidemic and the other outlining the
programmatic response to HIV. Both make recommendations that will inform The Global
Fund application.
The reports will be posted on the WHO EURO web site.
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Appendix Two:
Summary of meetings
WHO Regional Office for Europe
Mission to Albania
HIV programme evaluation
8-12 September, 2014
September 8, 2014
9.00-10.00
Meeting with representatives of the Ministry of Health
Dr Gazmend Bejtja- Director, Health Care Department
Dr Roland Bani
11.00-13.00
Meeting with the Department of Infectious Diseases at University Hospital
Centre
Topics: HIV testing, counselling, treatment and care including national and
Global Fund supported programs; national HIV programme framework,
including surveillance, prevention, PMTCT, co-infections, referrals, clinical
reporting system; national funding for HIV programs in the country, HIV
prevention, treatment and care interventions in the context of Global Fund
support.
Dr Silvia Bino
Dr Roland Bani
Dr Marjeta Dervishi
14.00-17.00
Meeting with the National Institute of Public Health
Topics: HIV prevention, treatment and care system, national guidelines on
prevention, treatment and care, national surveillance protocols, national
studies and additional surveys conducted to monitor the overall situation in
the country, ART monitoring. The meeting will identify national level
interventions and discuss examples from country’s sites/districts (if any).
Dr Roland Bani,
Dr. Marjeta Dervishi
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9 September 2014
10.00-12.00
Meeting with representatives from local organizations implementing HIV
prevention, treatment and care activities with focus on key populations
Aksion Plus
STOP AIDS
PLWHIVA association
13.00-14.00
Observers in the national AIDS advisory group meeting to discuss The
Global Fund application
15.00-17.00
Site visit to Department of Infectious Diseases at University Hospital Center
Facility assessment: provision of services, quality of provided services,
coverage, health status and procurement of ART
-
Dr Arjan Harxhi
Dr Daniela Nika, Vice Director, Anilinda Pogoj, Liridan Cake (procurement
team, Tirana University Hospital)
10 September 2014
9.00-10.00
Site visit to Tirana VCT centre
-Ermelinda Murati, Chief epidemiologist
- Ina Gishto, psychologist
10.13:00
Site visits to NGO to assess prevention and MMT programmes, including
interviews with sex workers/PWIDs.
-Arian Bocci
- Dr Pasho Maksuti
- and other representitives and clients of Aksion Plus (an NGO providing NSP)
13.00 – 17.00 Meeting with IPH and technical advisor for the Global Fund to discuss
preliminary findings and The Global Fund Application
- Dr Roland Bani
- Dr Roger Drew
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11 September 2014
10.00-11.00 Meeting with representative
- ALGA (Albanian lesbian gay association)
12.00 – 13.00 Meeting with CCM
Concluding meeting with all national counterparts, including
representatives of the Ministry of Health, CCM, National Institute of Public
Health, Department of Infectious Diseases at University Hospital Center,
other leading national entities and community representatives
Topic: National HIV programme in light of the Global Fund grant application.
Debriefing for national counterparts included inputs on the current situation,
discussion on identified possible gaps and recommendations on next steps,
agreement on follow up actions within the technical assistance
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Appendix Three: Presentation given to the country coordinating team on day four.
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